What antibiotics (Abx) are recommended for pediatric gastroenteritis in kids?

Antibiotics for Gastroenteritis in Children

Most children with gastroenteritis do not require antibiotics, but when indicated, azithromycin is the preferred first-line agent for Shigella and Campylobacter infections, while ceftriaxone is recommended for severe Salmonella infections. 1, 2

When Antibiotics Are NOT Indicated

• Routine antibiotic use is not recommended for most pediatric gastroenteritis cases, as the majority are viral in origin (primarily Rotavirus and Norovirus) and self-limiting 3, 4
• Never treat STEC O157 or Shiga toxin-producing E. coli with antibiotics, as this increases the risk of hemolytic uremic syndrome 2
• Avoid empiric treatment in immunocompetent children with watery diarrhea without specific risk factors 2
• The presence of bacteria on multiplex PCR does not equal causation and may represent colonization rather than active infection 2

Specific Indications for Antibiotic Treatment

Antibiotics should be considered in these specific scenarios:

• Infants < 3 months of age with suspected bacterial etiology 2
• Severe dysentery syndrome (bloody diarrhea with fever and systemic toxicity) 2
• Recent international travel with fever ≥38.5°C and/or signs of sepsis 2
• Immunocompromised patients with severe illness and bloody diarrhea 2
• High-risk Salmonella patients: infants <3 months, immunocompromised, sickle cell disease, or severe systemic illness 2
• Shigellosis (always treat due to risk of spreading and severity) 3, 4

Pathogen-Specific Antibiotic Recommendations

Shigellosis

• First-line: Azithromycin (preferred due to rising resistance to fluoroquinolones and trimethoprim-sulfamethoxazole) 1, 2, 4
• Azithromycin demonstrates shorter duration of diarrhea compared to ciprofloxacin and erythromycin 2

Severe Salmonellosis (when treatment indicated)

• First-line: Ceftriaxone 50-75 mg/kg/day every 12-24 hours 1, 2
• Alternative: Ciprofloxacin 20-30 mg/kg/day every 12 hours (but avoid in children <18 years if alternatives available) 1, 2

Campylobacter Infections

• First-line: Azithromycin (particularly effective when given early in illness) 1, 2, 4
• Treatment only warranted for severe cases, especially in the initial phase 4

Cholera

• First-line: Azithromycin 2
• Alternatives: Doxycycline or ciprofloxacin 2

Empiric Treatment Regimens (Before Pathogen Identification)

Only use empiric therapy in severe sepsis or high-risk patients 2, 3, 4

Preferred Empiric Options:

• Azithromycin (preferred empiric treatment for severe cases based on local susceptibility and travel history) 2
• For infants <3 months: Third-generation cephalosporin (ceftriaxone or cefotaxime) 2
• For severe sepsis/high-risk patients: Ciprofloxacin 20-30 mg/kg/day every 12 hours plus metronidazole 30-40 mg/kg/day every 8 hours 1
• Alternative: Aminoglycoside-based regimen 1

Critical Caveats and Pitfalls

• Fluoroquinolones (ciprofloxacin) should be avoided in children <18 years and pregnant women when alternatives exist due to musculoskeletal concerns 1, 2, 5
• Antibiotic resistance is a major global concern in Salmonella, Shigella, and Campylobacter, significantly limiting therapeutic options 1, 2, 3
• Empirical treatment without bacteriological documentation should be avoided in most cases 1, 4
• Metronidazole should only be prescribed for acute intestinal amebiasis after microbiological confirmation 3
• The routine use of broad-spectrum antibiotics is not indicated for all children with fever and abdominal pain when there is low suspicion of complicated intra-abdominal infection 6, 1